Radical Vaginal Hysterectomy and Laparoscopic Lymphadenectomy Kenneth D.

Hatch Schauta first introduced radical vaginal hysterectomy in 1902 in order to decrease the high mortality rate of the Wertheim abdominal hysterectomy (1). The procedure was not widely accepted because the pelvic lymph nodes could not be removed vaginally. Pelvic lymphadenectomy became an important part of staging and treatment of early cervical cancer in 1951 with the report of Meigs, but it required the use of an abdominal approach (2). With the introduction of laparoscopic lymphadenectomy, the Schauta vaginal hysterectomy was reintroduced. Laparoscopic pelvic lymphadenectomy with paraaortic lymph node sampling has become an accepted technique in the treatment of cervical cancer (3,4,5). Dargent was the first to suggest that the laparoscopic pelvic node dissection could be followed by a Shauta radical vaginal hysterectomy and reported a 3-year survival on 51 patients at 95.5%. Querleu reported a blood loss of less than 300 mL, a 4.2 hospital day stay, and less pain in a series of eight patients (6). Hatch et al. reported 37 patients with a mean operative time of 225 minutes, a blood loss of 525 mL, and an average hospital stay of 3 days (7). The major advantage over an abdominal operation was an 11% transfusion rate compared with a range of 35% to 95% reported in the literature for radical abdominal hysterectomy. Schneider reported 33 patients with a transfusion rate of 11% (8). Each of the authors reported some complications from the radical vaginal hysterectomy early in the series, with a decrease in incidence as experience was gained. Comparable long-term survival with radical abdominal hysterectomy has been reported by Hertel et al. in 200 patients with a mean follow up of 40 months (9). The projected 5-year survival is 83%, and for the 100 patients who were stage I and node negative the survival was 98%. The ability of the laparoscopic pelvic lymph node dissection to adequately identify all positive pelvic lymph nodes had been demonstrated by Querleu, Childers, and Fowler (5,10,11). The ability of the laparoscopic-assisted Shauta to adequately treat the primary tumor is most likely to be dependent upon the surgeon. The large published series of the Shauta operation by Massi et al. and Dargent et al. indicate that the Shauta procedure results in survival outcomes comparable to that achieved by the Wertheim-Meigs operation (12,13). The major obstacle to gaining widespread acceptance of the procedure is the lack of training in performing the Shauta operation, which leads to a high complication rate in the beginning of every series. The issue of blood loss and transfusion also is very important to patients and surgeons, since the identification of the human immunodeficiency virus. Every report on laparoscopic node dissection and radical vaginal hysterectomy has noted a significant decrease in blood loss with transfusion rates of less than 15%. Other societal advantages are the decreased hospital stay and rapid return to normal function, even with the radical surgery. P.166 Technique The patient preparation begins with a clear liquid diet the day before the surgical procedure. The patient is given a laxative to evacuate the bowel. It is important for the bowel to be collapsed during lymphadenectomy so that the proper exposure can be obtained. The patient is positioned in the dorsal lithotomy position with the legs in stirrups, which support the legs and decrease the tension on the femoral and peroneal nerves. The arms are tucked at the side, an orogastric tube is in place, and a Foley catheter is in the urethra. A 10- to 12-mm trocar is inserted into the umbilicus. Additional trocars are placed in the right and left lower quadrants just lateral to the inferior epigastric vessels. A 10- to 12-mm trocar is placed in the suprapubic site so that the lymph nodes can be removed through the port. The

patient is placed in the Trendelenburg position to help pack the bowel into the upper abdomen. The principles of laparoscopic surgery are similar to those of laparotomy. There must be adequate exposure, identification of anatomy, and removal of the appropriate structures. Sponges or minilaparotomy packs can be placed around loops of bowel to aid in exposure and to block small amounts of blood. This decreases the necessity for a suction apparatus in the abdomen and allows the port to be used for graspers or cautery. The paraaortic node dissection is usually performed first. Both the right and left sides of the aortic nodes are sampled. The peritoneum is incised between the sigmoid mesentery and the small bowel mesentery up to the duodenum. The node chain is isolated and dissection is carried out using electrosurgical techniques. Monopolar surgery, bipolar surgery, harmonic scalpel, and argon beam coagulator have all been used successfully. The landmarks for dissection are the reflection of the duodenum, the inferior mesentery artery superiorly, and the psoas muscles laterally. The ureter must be identified and placed on traction by the assistant to keep it out of the operative field. Common iliac nodes can be exposed through the retroperitoneal incision made from the paraaortic node dissection site. It is possible to resect the upper portion of the common iliac nodes from this approach, and the remainders of the common iliac nodes are dissected from the pelvic node incision sites (Fig. 14.1). The pelvic node dissection is begun by dividing the round ligaments and finding the lateral pelvic space. The obliterated umbilical artery is retracted medialward, opening up the entire lateral pelvic space. An entire lymphadenectomy is performed including the nodes between the iliac vessels and psoas muscle. The obturator space is dissected in its entirety. The node dissections are best performed by the surgeon on the side opposite of the dissection. Following the complete pelvic lymphadenectomy, the paravesical and pararectal spaces are open. The uterine artery is identified and isolated at its origin (Fig. 14.2). It is then divided and brought up and over the ureter. The uterine vein is likewise transected and mobilized medially. The cardinal ligament is then detached from the pelvic sidewall with a combination of sharp dissection and harmonic scalpel, clips, or stapler for hemostasis. This ensures that all of the lateral cardinal ligament tissue is removed. The ureter is dissected away from its peritoneal flap and the cardinal ligament tunnel is developed. The peritoneum over the uterosacral ligament is divided at the level of the rectum. The ligament is dissected sharply and with the aid of the harmonic scalpel or electrosurgical cautery to drop the rectum away from the uterosacral ligaments. The bladder flap has been advanced and the vesicouterine ligament is sharply divided using cautery when necessary.

Figure 14-1 Completed paraaortic node dissection with aorta, vena cava, and common iliac nodes removed. The surgical procedure then moves to the vaginal side. The legs are brought up from the lithotomy position and the P.167 cervix is exposed. Dilute epinephrine solution (1-100,000) is injected circumferentially under the vaginal mucosa, approximately 3 cm from the cervical vaginal junction. The prevesical space is developed and a curved retractor is placed. The vaginal mucosa in the posterior culde-sac incised and the rectum is dropped away.

Figure 14-2 Right pelvic sidewall after the node dissection before dividing the uterine artery.

Figure 14-3 Exposure of bladder pillars from vaginal side. The bladder pillar is developed by grasping the vaginal mucosa at approximately three o'clock; the Metzenbaum scissors are used to dissect submucosally until the paravesical space is entered. This is enlarged so that a Breisky retractor can be placed. This then isolates the bladder pillar from the cardinal ligaments (Fig. 14.3). The cardinal ligament attachments to the vagina are then clamped at the sidewall, divided, and ligated. This allows for greater mobility of the uterus and easier dissection of the ureter in the bladder pillar. The bladder

pillar is then dissected sharply until the ureter is found at the midportion of the bladder. The ureter undergoes a sharp bend at this point and as it is dissected out the uterine vessels become visible (Fig. 14.4). The vessels are then brought under the ureter and the ureter is freed from the rest of the attachments and pushed cephalad. Usually there are further peritoneal attachments that need to be divided and the specimen can be removed (Fig. 14.5).

Figure 14-4 Left ureter exposed from its bladder pillar.

Figure 14-5 Surgical specimen. After hemostasis is assured, the peritoneum from the bladder is sewn to the anterior edge of the vaginal mucosa. The peritoneum from the cul-de-sac over the rectum is sewn to the posterior vaginal mucosa. This allows for greater length of the vaginal to be established by inward migration of the squamous epithelium. The carbon dioxide is re-insufflated and the pelvis is inspected for hemostasis and for any unsuspected injuries to the bladder or ureter (Fig. 14.6). The pelvis is irrigated and the 10 to 12 mL trocar sites are closed with absorbable suture. The carbon dioxide is allowed to escape and the skin is closed with 4-0 absorbable suture or skin adhesive. P.168 Marcaine is injected in the skin incision sites to decrease postoperative pain.

Figure 14-6 View of the pelvis after completion of the surgery. Patients are given a clear liquid diet the night of the surgery and a regular diet the morning after surgery. They are generally able to be discharged on the second or third postoperative day. Complications of laparoscopy for malignant disease are higher than for benign disease. Postoperative complications of wound infection, ileus, and fever occur but at lower rates than after laparotomy. Adynamic ileus is unusual after laparoscopic surgery, but any abdominal distention, worsening of pain, or vomiting must be taken seriously. Unsuspected bowel injuries manifest themselves by abdominal distention, pain, and free air. The carbon dioxide used for insufflation should be absorbed within hours, so any free air in the abdomen is highly suspicious of perforation. Data on complication rates from laparoscopic lymphadenectomy are inadequate due to small sample sizes, lack of adjustment for a learning curve, and confounding by combinations of and differences in procedures. The author has not observed postoperative lymphocyst formation in more than 140 cases. Summary Laparoscopic lymphadenectomy followed by radical vaginal hysterectomy is an excellent option for patients with stage IA or IB cancer of the cervix. Compared with radical abdominal hysterectomy and lymphadenectomy, it has less blood loss, fewer hospital days, and more rapid return to full activity with comparable survival. References 1. Schauta F. Die Erweiterte Vaginale Totalextirpation des Uterus beim Kollumkarzinom Verlag von J. Safar, Wien und Leipzig, 1906. 2. Meigs JV. Radical hysterectomy with bilateral pelvic node dissections; a report of 100 patients operated on five or more years ago. Am J Obstet Gynecol. 1951;62:854870. 3. Dargent D. A new future for Schauta's operation through a presurgical retroperitoneal pelviscopy. Eur J Gynaecol Oncol. 1987;8: 292-296. 4. Hatch KD, Hallum AV, Nour M. New surgical approaches to the treatment of cervical cancer. J Natl Cancer Inst Monogr. 1996;21: 71-75. 5. Querleu D, Leblanc E, Castelain B. Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix. Am J Obstet Gynecol. 1991;164:579581. 6. Querleu D. Laparoscopically assisted radical vaginal hysterectomy. Gynecol Oncol. 1993;51:248254. 7. Hatch KD, Hallum AV, Nour M, et al. Comparison of radical abdominal hysterectomy with laparoscopic assisted radical vaginal hysterectomy for treatment of early cervical cancer. J Gyn Tech. 2000;6:36.

8. Schneider A, Possover M, Kamprath S, et al. Laparoscopy-assisted radical vaginal hysterectomy modified according to Schauta-Stoeckel. Obstet Gynecol. 1996;88:10571060. 9. Hertel H, Kohler C, Michels W, et al. Laparoscopic-assisted radical vaginal hysterectomy (LARVH): Prospective evaluation of 200 patients with cervical cancer. Gynecol Oncol. 2003;90:505511. 10. Childers JM, Hatch K, Surwit EA. The role of laparoscopic lymphadenectomy in the management of cervical carcinoma. Gynecol Oncol. 1992;47:3843. 11. Fowler JM, Carter JR, Carlson JW, et al. Lymph node yield from laparoscopic lymphadenectomy in cervical cancer: A comparative study. Gynecol Oncol. 1993;51:187192. 12. Massi G, Savino L, Susini T. Schauta-Amreich vaginal hysterectomy and WertheimMeigs abdominal hysterectomy in the treatment of cervical cancer: A retrospective analysis. Am J Obstet Gynecol. 1993;168:928934. 13. Dargent D, Brun J, Roy M, et al. Pregnancies following radical trachelectomy for invasive cervical cancer. Gynecol Oncol. 1994;54:105.